Dec 8 The Cancer Crossroad for Rural Appalachia: A Call to Reform Major Health Disparities

A recent study published in The Journal of Rural Health that was conducted by researchers in the Department of Public Health Sciences at the University of Virginia’s School of Medicine is shedding light on ominous data from cancer trends in rural Appalachia since the mid-1990s (1). The study shows that individuals diagnosed with cancer who are living in rural Appalachia can have up to 36% higher mortality rates, 15% higher incidences of cancer, and 8% lower 5-year survival rates than their peers with the same diagnosis living in an urban non-Appalachian area of the United States (1). In fact, 7 of the 13 states that comprise Appalachia in its entirety, could have collectively saved 90% of the 16,000 lives lost to cancer in rural Appalachia if mortality rates were equal to those seen in urban non-Appalachian areas (1). Clearly, there is a cancer crisis in Appalachia.

Why are Appalachians facing dire cancer mortality, incidence, and survivorship rates apart from the rest of the nation? Researchers believe that the root of the crisis stems from several healthcare and socioeconomic disparities that disproportionately affect areas of rural Appalachia from the urban grid. Among these include higher rates of smoking and obesity, lower rates of cancer screening and access to healthcare facilities for long-term cancer treatments, overall increases in poverty and lower household incomes since the Great Recession when compared to their urban counterparts, and lower rates of health insurance (1). The study also notes that outmigration of healthy, working-age individuals from rural Appalachia to more economically advantageous areas could have also contributed to the disproportional dataset (1). Two of the major contributors that have had lucid impacts on the cancer crisis are lower recommendations for cancer screenings by healthcare professionals and slower implementation of cancer treatments in rural Appalachia areas since the mid-1990s due to prohibitive high monetary costs (1).

When healthcare facilities for cancer treatments are not made readily available or are harder to access by low-income individuals and families, it is not hard to imagine how a deadly dynamic is created for those who need care the most. From this point forward, Appalachia is at a real crossroad; will it continue to allow social disparities to guide cancer trends, or will systematic solutions and holistic efforts be made to carve a progressive future for cancer-related and general healthcare?

A call to action must be made to ensure that Appalachians, which actually make 8% of the total U.S. population, are on the path to comprehensive solutions and strategies that will create equal opportunities for healthcare access and cancer treatments (2). Some might argue that a holistic approach to solving the current cancer crisis in rural Appalachia is too big to even begin crossing, but this is simply not the case. One methodology of enacting social reform and justice, known as liberationist theory, has been utilized effectively in several nations around the world for essential healthcare progress. That is to say, liberationist theory is much more than an idea; it is an actual practice for solving social and health disparities.

Two of the core leaders in the discussion of liberationist theory are Dr. Paul Farmer and Fr. Gustavo Gutiérrez, who both write a detailed account of the practical and necessary implementations of such an approach to solving medical crises. In their book, In The Company of The Poor, Farmer and Gutiérrez highlight the essential need of public health services to give preferential options to the poor, especially those from rural areas around the world who face gaps in the delivery of healthcare, increased rates of avoidable deaths, and heavier burdens during disease outbreaks than more urbanized communities (3). To give a larger perspective of the true pervasiveness of medical crises in poor and rural areas everywhere around the globe, Farmer and Gutiérrez note that nearly ten million people, “almost all of them poor, died in the 1990s from malaria, tuberculosis, AIDS, ...and cancers for which therapy had been shown to be effective” (3). Yet, today, over two decades later, we are still witnessing the continuation of premature deaths from cancer diagnoses in rural Appalachia.

The liberationist approach that Farmer and Gutiérrez have identified and applied in real cases around the world promotes pragmatic solidarity with communities and aiding health disparities through actual praxis. For example, the cholera epidemic that followed the 2010 earthquake in Haiti was first remedied by identifying the origin of the cholera pathogen in the rural streams and rivers near the fault lines, which carried the cholera pathogen rapidly to many local sources of drinking water (3). However, Farmer and Gutiérrez argue that the greater social disparities that contributed to the cholera outbreak were a lack of public investment in modern sanitation for safe drinking water, as well as lack of access to healthcare for the rural poor (3). It is therefore these larger social determinants that must be identified and amended, along with directly treating the sick, in order to holistically solve a medical crises disproportionately witnessed by the poor and vulnerable (3). As such, community organizations and grassroots efforts were able to not only gather the medicines needed to treat cholera, which resulted in a zero mortality rate with early diagnoses and readily available care, while resources were also made available on the ground to improve the sanitation of local drinking water (3).

Some might argue that the strategy that Farmer and Gutiérrez propose is too utopian or ambitious to solve the cancer crisis in rural Appalachia, because unlike cholera, cancer is a chronic disease. How can liberationist strategies used to easily combat illnesses with vaccines or antibiotics be equated to addressing the treatment of cancer, which requires long-term healthcare services? It turns out that this has already been done in Rwanda, in which more than 80% of people live in rural areas (3). In 2012, Rwanda partnered with U.S. medical centers to train both physicians and nurses in the fields of oncology and pediatric cardiology, because both were deemed national healthcare priorities (3). By 2019, Rwanda planned to dramatically strengthen its public health systems and increase its doctor-to-patient ratio for better success in diagnosing and caring for long-term patients, especially those with cancer (3). Today, mortality rates in Rwanda have decreased at one of the steepest rates ever documented in history, and it is the only sub-Saharan country in Africa to meet all of its health-related Millennium Development Goals for 2015 (3).

To what does Rwanda’s incredible healthcare reform owe its success? The answer is in the power of “equity response,” which Farmer and Gutiérrez define as the “preferential option for the poor in healthcare and related social services” (3). By implementing solutions of pragmatic solidarity, such as creative modes of healthcare delivery in community-based centers, nurse-run clinics, and district hospitals, the healthcare needs of those living in rural and low socioeconomic areas are prioritized (3). Rural Appalachia can follow the example of Rwanda by utilizing private sector partners, including religious communities and nongovernmental institutions, to creative a manageable and innovative model in which all parts work together as a whole to mimic standard public health sector care and services (3).

Changing the status quo is never an easy task, but introducing new policies and practices within a long-standing paradigm of social and health disparities is vitally important to the future for rural Appalachians, as well as all global citizens. Human progress relies on helping the needs of the most vulnerable, the poor, by not only providing access and availability to basic and specialized healthcare, but also accompanying communities to reach their highest potential through solidarity. In the future, many might be quick to assume that rapid urbanization of rural Appalachia is the quickest way to enact economic growth and overall social prosperity, but this approach has been proven to only lead to further collapse of rural healthcare systems, while it might not be in the interest of the rural communities to urbanize in the first place (3). This is why it is paramount to not only listen to the healthcare needs of the rural communities directly, but to also accompany them in solidarity and a liberationist approach for greater social transformation, which has many factors at play. Just as Farmer and Gutiérrez explain in their text, “Attempts to address individual pieces of health without consideration of the whole are as the Haitian proverb goes, ‘like washing your hands and drying them in the dirt’” (3).

In the end, individuals suffering from cancer-related health disparities in rural Appalachia deserve to have their individual voices and collective concerns about the cancer crisis prioritized in both the public health systems and private sector organizations that have power to impact social transformation in the current climate. A liberationist approach that empowers community-based solidarity, equity response, and pragmatic praxis should guide the future decisions and solutions that rural Appalachians will have to face in the wake of alarming health disparities. As such, the current cancer crossroad offers a path for opportunity and reform that rural Appalachians must begin to carve.

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